This agreement is between the patient and North Country Adult Medicine (NCAM). It is agreed that narcotic medication will be given by Dr. Cichetti on a regular basis to the patient only if the following terms are met:

1. By signing a contract for narcotic administration, the patient indicated that he/she has understood the discussion about the use of narcotic medications, including side effects, and is agreeable to start this treatment under the terms set by NCAM.
2. The patient has the chance to ask questions regarding alternatives to the use of narcotic medications.
3. Dr. Cichetti should be the one and only source of narcotic medications unless written permission is given by Dr. Cichetti for the patient to get narcotic prescriptions from another physician.
4. Only one pharmacy will be used for filling narcotic prescriptions.
5. If it is found that the patient received prescriptions for narcotic medications from a source other then Dr. Cichetti, without written permission, NCAM may void this agreement and discontinue any prescriptions of narcotic medications to the patient.
6. The patient agrees to have urine tests for medications and illicit substances done randomly at the physician’s request.
7. The patient must agree to allow Dr. Cichetti to communicate with other treating
   physicians and any pharmacists regarding the patient’s use of controlled substances.
8. The patient must supply documentation of treatment by other physician for co-existing, or related condition, including psychiatric conditions.
9. The patient understands that NCAM will not replace any lost or inaccessible narcotic
   prescriptions or narcotic medications, for ANY REASON.
10. The patient must supply documentation of treatment by other physician for co-existing, or related condition, including psychiatric conditions.
11. The patient must take the narcotic medications exactly as instructed by Dr. Cichetti.
12. Any unauthorized increase in the dose of narcotic medication may be viewed as a cause for discontinuation of the treatment with narcotic medications.
13. If the patient demonstrates unacceptable behavior patterns, Dr. Cichetti may discontinue prescribing the narcotic medications for the patient.
14. The patient must keep all regular follow up appointments as recommended by Dr. Cichetti. Failure to comply may cause discontinuation of narcotic prescriptions.
15. The patient must comply with all aspects of the treatment plan, including, but not limited to: Physical Therapy, Behavioral Management, and self-help programs.
16. All controlled substances require an appointment in our office for any refill of the medication. This means that you will need to be seen every 28 days if you take the medication regularly.
17. No narcotic prescriptions will be refilled on weekends or over the phone.
18. Narcotic prescriptions WILL NOT be refilled early.
19. The patient understands that the benefit of the narcotic medications will be evaluated
    periodically using the following criteria: pain relief, increase in general functions, increase in exercise, completion of rehabilitation program, return to work, maintenance of job, etc.
20. The patient understands the narcotic medications can be discontinued immediately, at the treating physician’s discretion if the patient does not fulfill the terms of this agreement. Medication can also be discontinued if there is evidence of rapid tolerance, loss of effectiveness or if significant side effects develop.
21. The patient certifies or agrees to the following:
    a) That he/she is not currently abusing illicit or prescription drugs.
    b) That he/she has never been involved in the sale, illegal possession, diversion or transport of controlled substance (narcotics, sleeping pills, nerve pills, or pain killers).
    c) That she is not pregnant and that she will use appropriate contraception during her course of treatment.
    d) Sharing your narcotics is strictly prohibited. Any sharing will result in immediate cancellation of your prescription refills.
    
22. Evidence of medication hoarding, increasing the amount of medication with out communication to your physician, refilling your prescription too frequently, getting the medication from multiple physicians, increasing the amount of medication despite significant side effects, altering prescription, medication sales, unapproved use of other drugs (alcohol, sedatives, or using non-prescription, medications inconsistent with drug labeling) during narcotic analgesic treatment or other unacceptable behavior will result in tapering and discontinuing of narcotic therapy.
23. If the patient is non-compliant or un-cooperative with the Physician or Office Staff we reserve the right to discharge you at any time.

I fully understand the explanations regarding the benefits and the risks of this method of treatment. I agree to the use of narcotic medication in treatment of my pain problem. This for has been fully explained to me, I have read it or have had it read to me, and I understand it. I have had the opportunity to ask questions, and have received acceptable answers. I agree to the terms of this contract.